IMAGES IN MEDICINE
Heart, Lung and Vessels. 2014; 6(3): 210-212
210
Internal thoracic vein:
friend or foe?
A. Roubelakis, D. Karangelis, S.K. Ohri
Department of Cardiothoracic Surgery, Southampton University Hospitals NHS FoundationTrust, Southampton, UK
Keywords: graft elongation, coronary artery bypass,
revascularization.
The internal thoracic vein is a conduit that
has not been thoroughly investigated in literature as long term patency and outcomes
are unknown.
We present a case where the right internal
thoracic vein (RITV) was used to extend a
short right internal thoracic artery (RITA).
The elongated composite conduit was then
anastomosed to the right coronary artery
(RCA).
A 61-year-old male patient was referred
electively for a coronary artery bypass
grafting (CABG) operation.
The patient had undergone extensive
stenting to the left and right coronary artery systems. Unfortunately the stents to
the right coronary artery had restenosed
causing significant symptoms necessitating
revascularization (Figure 1).
From the conduit point of view, the patient had his long saphenous veins fully
stripped bilaterally. His radial arteries
were assessed with Allen’s test and use of
saturation monitor: following the occlusion of the radial the saturations failed to
rise, therefore they were deemed unusable.
RITA was therefore elected to be the conduit of choice.
Corresponding author:
Dimos Karangelis MD, PhD
Wessex Cardiac Centre
Southampton University Hospitals
FoundationT NHS Trust
Tremona Road, Hampshire, UK
e-mail: dimoskaragel@yahoo.gr
Figure 1 - Preoperative angiogram showing an instent occlusion of the mid-distal RCA.
RCA = right coronary artery.
The operation was performed in a standard
on-pump fashion. RITA was harvested initially as a pedicled graft.
The target vessel was measuring approximately 1.5 mm in diameter and was opened
distally due to the presence of the previous
stents and the anatomy of the lesions. Unfortunately RITA intima was found to be
of suboptimal quality and calibre distally
and had to be shortened.
This resulted in RITA length being insufficient to reach the target vessel, even with
skeletonisation. RITA was then extended
with a 2-3 cm segment of RITV which appeared to be of good quality and calibre.
The reversed RITV and RITA were anastomosed in an end-to-end fashion using
continuous 8-0 polypropylene suture (Figure 2).
The composite graft was then anastomosed
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Internal thoracic vein: friend or foe?
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Figure 2 - The end to end anastomosis (circled) between the RITA and RITV. There is no mismatch in
the calibre of the two vessels.
RITA=right internal thoracic artery; RITV = right
internal thoracic vein.
Figure 3 - The composite conduit as viewed from
the patient’s head after the completion of the distal
anastomosis.
distally to the RCA (Figure 3) and proximally to the ascending aorta. There was
excellent flow down this graft. The operation was completed uneventfully and the
patient was discharged home on the 5th
postoperative day. He remains symptomfree at a 6 month follow up.
The ITV conduit studies in literature are
very limited as they have not being used
routinely, therefore long term results are
unknown. The use of any other venous
conduit (like short saphenous or cephalic
veins) was not preferred due to patient’s
age and would also lead to significant size
mismatch between the RITA and the vein,
if used as extentions. Left internal thoracic
artery (LITA) needed to be preserved for
possible future revascularization on the
left coronary system. The use of gastroepiploic artery is not performed routinely in
our unit and therefore experience is very
limited.
There is only one study in literature where
ITVs were used as CABG grafts to the left
anterior descending artery in a minipig
model. The authors measured significant
intimal hyperplasia in these grafts after 4
weeks (1). Similar studies to humans however have not been performed.
A report from 1990 presented a 57 year old
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212
patient who underwent CABG operation
with the use of left and right ITAs and internal mammary vein (IMV). to an obtuse marginal. Angiography after 10 days revealed
excellent patency of the IMV graft (2).
It is difficult to justify the use of internal
thoracic veins as conduits for CABG, as in
most cases there is ample selection of other
well established conduits. The calibre of
these veins is similar to internal mammary
arteries (IMAs) and could potentially be
used as extensions. ITA elongation has
been described before with the utilization
of various grafts (3,4). To summarise, our
method could potentially be useful when
the internal mammary artery is not long
enough to reach the target vessel when no
other option is possible.
The major limitation of this report is that
a postoperative angiogram to assess the
patency of the graft could not be obtained.
There is no need of ethical committee approval for this case report. Written informed consent was obtained from the patient.
REFERENCES
1. Popov AF, Dorge H, Hinz J, Schmitto JD, Stojanovic T,
Seipelt R, et al. Accelerated intimal hyperplasia in aortocoronary internal mammary vein grafts in minipigs. J Cardiothorac Surg. 2008; 3: 20.
2. Stephan Y, Jebara VA, Fabiani JN, Carpentier A. The internal mammary vein: a new conduit for coronary artery
bypass. J. Thorac. Cardiovasc. Surg. 1990; 99: 178.
3.Calafiore AM, Teodori G, Di Giammarco G, Vitolla G,
Contini M, Maddestra N, et al. Left internal mammary
elongation with inferior epigastric artery in minimally invasive coronary surgery. Eur J Cardiothorac Surg. 1997;
12: 393-6; discussion 397-8.
4.Bernet FH, Hirschmann MT, Reineke D, Grapow
M, Zerkowski HR. Clinical outcome after composite grafting of calcified left anterior descending arteries. J Cardiovasc Surg (Torino) 2006; 47: 569-74.
Cite this article as: Roubelakis A, Karangelis D, Ohri SK. Internal thoracic vein: friend or foe? Heart, Lung and Vessels. 2014;
6(3): 210-212.
Source of Support: Nil. Disclosures: None declared.
Acknowledgment: We thank Anne Gale for editorial assistance.
Heart, Lung and Vessels. 2014, Vol. 6